I …………………………………………….. son/daughter/wife of ……………………………
an employee of …………………………………… …………………………. (Name of the
Establishment) code No. …………………………….. authorise the Commissioner to :

(i) Withdraw a sum of Rs. …………………………..….. (Rupees
…………………………………………………) only from my Provident Fund Account No.
………………….. and remit the same to the Life Insurance Corporation of India towards
the initial premium in respect of my Life Insurance Policy/Proposal for Life Insurance
details of which are given herein :

(ii) make periodical withdrawal of Rs………………………………………(
Rupees …………………………….….. only) from my Provident Fund Account No .
……………………… each time the premium falls due for payment and remit the same
to the Life Insurance Corporation of India towards the premia in respect of my LifeInsurance policy, details of which are given herein so as to reach he said Corporation
within the time allowed for each payments.

(iii) to convert the said insurance policy into a paid up one when the credit in
my Provident Fund relating to my own contribution becomes inadequate for the
payment of any premium, unless the payment of further premium is arranged by me
with the Life Insurance Corporation of India and I inform the Regional Commissioner
accordingly.

(iv) to pay late fees and/or interest of my own contribution in my ownProvident Fund account If any premium cannot be remitted to the said Corporation in
time because of delay in sending to the Commissioner the policy duly assigned to the
Central board of Trustees of the Employees’ Provident Fund or any other reason for
which I or my employer may be responsible.

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2. I accept that:

(i) The authorisation at para I (ii) above shall be effective only when my LifeInsurance Policy duly assigned to the Central Board of Trustees, Employees’ Provident
Fund has been received by the Commissioner after proper registration of the
assignment in the books of the said Corporation.

(ii) The said authorisation shall thereafter remain operative till such time as I
continue to be a member of the Fund and have enough accumulation to my credit as my
own share in the Fund, or till the maturity of the policy, whichever is earlier.

(iii) The terms of the policy shall not be altered nor shall the policy be
exchanged for another policy without the prior written consent of the Regional
Commissioner.

3 The policy is enclosed for inspection/ will be forwarded when received/has
already been assigned to the Central Board of Trustees of the Employees’ Provident
Fund and accepted by the Commissioner vide his letter No
……………………………..……….. dated the ………………………………..

4 I am aware that the policy is to be assigned to the Central Board of Trustees of
the Employees’ Provident Fund as security within six months of the date of the first
remittance by the fund to the said Corporation and sent to the Commissioner after
registration of the assignment in the Books of the said Corporation.

5 I declare that :

(a) I had been a member of the Fund for the period of not less than 2 years
which is a minimum period for being eligible for financing the Insurance Policy from the
Fund,

(b) The amount standing to my credit in my EPF. Account / my own share is
Rs …………………….. as on ………………………….. which is sufficient for making
payment to LIC for two years,

(c) My annual contribution to the fund is Rs. ………..…………… which is
sufficient to pay the yearly premium.

(d) I propose to nominate the same person for the P.F.

6. I also declare that the policy is free from any encumbrances and the details of the
policy / proposal given herein are correct to the best of my knowledge.

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7. Details of the policy/proposal :

(i) Address of the Branch Office or unit of the LifeInsurance Corporation where the policy account is to
be maintained

(ii) Policy/proposal No. & date

(iii) Sum assured/ proposed to be assured.

(iv) Probable date of purchase of the policy

(v) Whether the proposal has been accepted and
if so, by what date the first premium is to be paid

(vi) Cost of the policy (in the case of single
premium purchase)

(vii) Amount of yearly permia

(viii) Due date(s) for payment of premium.

(ix) Date of payment of last premium.

(x) Whether age has been admitted. If not state
the nature of proof presented to Life Insurance
Corporation

(xi) Name(s) of the nominee(s) under Section 39 of
the Insurance Act, 1938

(xii) Guardian appointed under Section 39 of theInsurance Act, 1938 in respect of minor nominees, if
any

(xiii) Details of any previous policy already assigned
to the C.B.T,

Or

“Certified that I have not withdrawn any amount
previously for financing any Insurance Policy out of
my Provident Fund Account.”

(xiv) Remarks

Date: Signature or ** Left/Right thumb impression of the
Member.

* Delete portion if not applicable.
** Left hand thumb impression in the case of illiterate male member and right hand thumb
impression by illiterate female member.

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Certified that this form has been signed/thumb impressed before me by …………
……………………………………………..A/c: No . …………………………………. employed in
……………………………………………………………….. (Name of the establishment)

Signature of the employer of his
authorised official
Date …………………… Designation
Code No. of the Establishment.
Name and address of the
Establishment & its stamp

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(For use in Regional Commissioner’s Office)

Accounts Section

Average of yearly Total contributions Whether any Whether the subscriber
contribution (employees’ (employees’ share other L.I.P. has contributed for two
share only) on the basis only) as on Advance has years.
of recent 12 months _________ been granted
before, f so,
mention the
date of
withdrawal

The above case has been examined vide Paras 62 to 64 of the Employees’ Provident Funds
Scheme, 1952. A sum of Rs. ……………………….. (Rupees
…………………………………………………………………………….. only ) may be paid.